Master the board step 3

Surgery
Vascular Surgery
A 48-year-old laborer complains of coldness and tingling in his left hand as well
as pain in the forearm when he does strenuous work. Recently he’s complained of
dizziness, with blurred vision and trouble keeping steady during these episodes.
Which of the following is the most important management?
a. Aspirin
b. Clopidogrel
c. Warfarin
d. Bypass surgery
e. Carotid endarterectomy
Answer: D. Bypass surgery is needed for subclavian steal syndrome.
Subclavian Steal Syndrome
Although this condition is rare in practice, it is a classic board vignette. An
arteriosclerotic stenotic plaque at the origin of the subclavian allows enough
blood supply to reach the arm for normal activity but not enough to meet the
increased demands of an exercised arm, resulting in blood being “stolen”
from the vertebral artery. When the arm is raised, increasing oxygen demand,
the vessels in the arm dilate to increase perfusion. This dilation acts as a
vacuum to blood in the head, neck, and shoulder, leading to syncopal episodes.
Classic symptoms are the following:
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Posterior neurological signs: Visual symptoms, equilibrium problems
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Claudication in the arm during arm exercises
Don’t confuse this condition with thoracic outlet syndrome, which causes
vascular symptoms only, with no neurologic signs.
Diagnose with an angiography.
Treatment is with bypass surgery.
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